Victimization among children and adolescents accessing the Meyer pediatric hospital: A retrospective study

Abstract Problem The consistent prevalence and occasionally severe consequences of bullying and victimization suggest the need to include a more accurate assessment of these episodes within the Emergency Departments (ED). However, the literature on mental health related symptoms of bullying/victimization treated in the ED is still scarce. The aim of this study is to assess the prevalence of peer victimization amongst children and adolescents referred to an Italian Pediatric Emergency Department. Differences between Hospital Departments, type of victimization and ages are tested. Methods A retrospective observational study was conducted with 705 subjects. The age range was from 6 to 18 years old (M = 13.09; SD = 3.048). Findings 15.3% of the sample reported to be victimized (8.2% occasionally; 7.1% systematically). For the Child and Adolescent Psychiatry Unit, we found a significant association between peer victimization and being adolescent (Fisher's p = 0.003). In addition, a significant association was found between verbal victimization and Child and Adolescent Psychiatry Unit (Fisher's p = 0.02) and physical victimization and Child Abuse Department (Fisher's p < 0.001). Conclusion Findings suggest the importance of an accurate assessment of victimization experiences of children and adolescents with access to ED, to prevent future re‐victimization and crystallization of symptoms across time.


| INTRODUCTION
Bullying and victimization constitute universal public health concerns that affect a significant proportion of children and adolescents around the world, having severe consequences for physical and psychological health (Menesini & Salmivalli, 2017;Wolke & Lereya, 2015;Zarate-Garza et al., 2017). The growing awareness of the prevalence and consequences of bullying and victimization in the general population has led to consider the possibility to include a more accurate assessment of these episodes within the Emergency Departments (ED) (Waseem et al., 2017). This can have several consequences and benefits in terms of taking charge of the victims with severe consequences, prevent possible re-victimization episodes, define more individualized interventions carried out by the ED or by the community services, help school in defining protocols for secondary and tertiary prevention. However, the literature on health and mental health related symptoms of bullying/victimization that are treated in the ED is still scarce, particularly in Italy. The current study aims to reduce this gap investigating the nature of victimization episodes reported by the children and adolescents who accessed to three different EDs of the Meyer Pediatric Hospital: a Psychological Department, a Child and Adolescent Psychiatry and Neurorehabilitation, and a Child and Adolescent Abuse Group Unit.

| Physical health and mental health consequences of bullying and victimization
The physical health consequences of bullying can be immediate, such as physical injury, or they can involve long-term effects, such as headaches, sleep disturbances, somatization and psychological consequences (National Academies of Sciences Engineering and Medicine, 2016). The study of physical injury as direct consequences of physical bullying, including hitting and kicking or tripping and pushing, received a very limited attention (Johnson et al., 2020) as compared to the attention paid to somatic and psychological consequences. Psychosomatic problems and a general poor physical health with a variety of symptoms, such as headache, backache, abdominal pain, skin problems, sleeping problems, bedwetting, or dizziness have been found to be associated with being victimized, in particular for boys (Gini & Pozzoli, 2013). A very consistent literature focused on psychological consequences related to being victimized, including depression, anxiety, self-harm and non-suicidal self-injury, and suicidal ideation and attempts (Moore et al., 2017). Few studies analyzed the role that the type of victimization has on health consequences. Some of them reported no significant differences between direct and indirect bullying on psychological (Yen et al., 2013(Yen et al., , 2014 and somatic complaints (Baldry, 2004). As regard cyberbullying, a meta-analysis has suggested that it is strongly related to psychological consequences such as depression and risks of suicidality (Yen et al., 2014;Zhou et al., 2013).
The majority of the studies on consequences of victimization used community samples and longitudinal prospective designs. However, little research has investigated health and mental health related symptoms of bullying/victimization that are treated in the ED (Waseem et al., 2017).
This literature distinguished studies focused on physical injuries or behavioral issues, and psychiatric and psychological symptoms related to bullying experiences treated in the ED.
As pertain to the first group all the studies were conducted in US samples. In particular, in a sample of urban adolescents referred to ED for physical injuries, 40% attributed the injury due to a bullying situation (Johnson et al., 2020). Amanullah et al. (2014) found that 12.5% of intentional injuries treated in the ED occurred in schools and that younger adolescents were more likely to attribute their injury to bullying situations. One study suggested that, among 591 youth treated in the ED due to behavioral issues, 24% reported bullying victimization (Waseem et al., 2013).
As pertain the second group, several studies showed evidence that a large proportion of children and adolescents who have experienced bullying come into contact with mental health services, although with a high rate of variation between studies. Kumpulainen et al. (2001) found that 44% of "bully/victims," 42% of "bullies," and 24% of "victims" had had contact with mental health professionals compared with 13% of controls. In a sample of 52 adolescents from a psychiatric outpatient service in England Salmon et al. (2000) reported that 27% of participants had been bullied. Bullying resulted a common problem in Canadian children and adolescents presenting to the ED with a mental health complaint, as approximately 77% reported experiencing bullying during their lifetimes (Alavi et al., 2015).
Another study conducted in Canada reported that the prevalence of bullying was 26.9% among adolescents referred by the ED for urgent psychiatric assessment (Roberts et al., 2016). In a clinical sample of 508 adolescents admitted to a Hospital Department of Psychiatry in Finland, 29.3% of boys and 38.3% of females were victims of bullying (Luukkonen et al., 2010). In a clinical psychiatric sample in Norway, 19% reported being bullied often or very often, and 51% reported being bullied from time to time (Hansen et al., 2014). In Italy, studies have investigated the effect of victimization on children and adolescent mental health in community samples (Gini, 2008;Menesini & Nocentini, 2015), but few studies yet were conducted on clinical populations at the EDs (Pisano et al., 2020). With the increasing number of children and adolescents being admitted to EDs with health complaints (Dolan et al., 2011;Pittsenbarger & Mannix, 2014), professionals should be more aware that these complaints could be also related to potential bullying situations. The ED represents an important location for secondary and tertiary prevention, intervening once an individual has been involved in violence. Having more information about the nature of the victimization cases entering into the EDs might be helpful to better define protocols for the primary and secondary prevention in schools. Besides, the ED may have a role to prevent the re-victimization through the guidance from ED providers and to facilitate the access to hospital or community interventions able to monitor the wellbeing of the victims. Unit (GAIA). Differences for ages (6-10 and 11-18 years old) and for type of victimization (physical, verbal, psychological and cybervictimization) will be taken into account.
Specifically, the PD deals with specialized assistance to children, adolescents and their families, in ordinary hospitalization, day hospital and outpatient conditions who are facing a chronic or acute illness, and somatic disorders (e.g., recurrent abdominal pain, dyspepsia, encopresis). The CAPN department deals with diagnosis, care and rehabilitation of children and adolescents with pathologies of psychiatric interest (e.g., depressive disorder, anxiety disorder, eating behavior disorders, posttraumatic stress disorder, somatic disorder).
Finally, the GAIA department is a service dedicated to the protection of the rights of minors, in terms of both prevention and detection of suspected cases of abuse, violence and/or maltreatment.

| Participants
The clinical sample included 705 children and adolescents, 319 males (45.2%) and 386 females (54.8%) accessed at Meyer Pediatric Hospital from October 2015 to December 2017. The age range was from 6 to 18 years old (M = 13.09; SD = 3.048). 145 subjects (20.6%) belonged to the age category 6-10 years and 560 (79.4%) to the age category 11-18 years. As regard the nationality, 83.7% of the sample was Italian and 16% was foreign. Sociodemographic and psychopathological data were coded from medical records. Peer victimization information were routinely assessed through medical interview performed on all subjects and their parents, without using instruments specifically aimed to measure these experiences. The experience of victimization in the past medical history was considered occasional when it was mentioned as once during the lifetime present in the clinical record and systematical when it was repeated during the lifetime.

| Procedure and analysis of data
The study variables included age, hospital department/unit, type of victimization and experience of victimization. The variables were extrapolated directly from the clinical records, entered in a computerized evaluation matrix, and later imported in the SPSS-PSW 18 software for statistical analysis. For the prevalence of victimization, we used the frequencies and percentages. To evaluate the impact of victimization within the different Departments of Meyer Pediatric Hospital we used contingency tables and the Chi squared test (χ 2 ).

| RESULTS
The effect of age has been tested within each Department separately (see Table 2).
In relation to the PD, any significant relation was found between the being victimized and the two age groups (Fisher's p = 1). The same results have been found for GAIA department (Fisher's p = 0.52).

| 315
As concern the CAPN department, there was a statistically significant difference between no victimization, occasional victimization and systematic victimization comparing the age group 6-10 years with the age group 11-18 years (Fisher's p = 0.003). Having an age between 11 and 18 is hence linked to a greater possibility of being victims. In particular, 2 (5.3%) subjects for the age group 6-10 years and 36 (94.7%) for the age group 11-18 years, were occasionally victimized. Instead, 28 (100%) subjects for the age group 11-18 years were systematically victimized.
In relation to the type of victimization, as we can see from other studies attesting around 19%-29% (Alavi et al., 2015;Hansen et al., 2014;Luukkonen et al., 2010;Roberts et al., 2016;Salmon et al., 2000). to 2015. Besides, the number of years examined ranged from 2 years (Roberts et al., 2016), 3 years (Hansen et al., 2014), 4 years (Alavi et al., 2015), to 5 years (Luukkonen et al., 2010). A second important explanation includes the specific ED considered in the studies. The majority of the studies considered the child and adolescent psychiatry department, whereas in our case we have three different EDs, characterized by different health needs. The age of the patients presented also a relevant heterogeneity. In the majority of the studies (Hansen et al., 2014;Luukkonen et al., 2010), adolescents, and not children, were considered. This contributes to register lower prevalence rates.
Regarding the presence of victimization into the three services of the Meyer Pediatric Hospital any significant difference was found.
In fact, we can see how the percentage of victims in the different departments is roughly the same.
Concerning the age group, we found that adolescents aged between 11 and 18 years accessing to CAPN department, are more likely to be victims as compared to children aged between 6 and 10.
This result confirms that adolescents are the main targets for peer victimization (Nocentini et al., 2013;Pellegrini & Long, 2002

ACKNOWLEDGMENTS
No external funding was received for this study. The authors would like to thank all the subjects who participated in this study. The authors have declared that they have no competing or potential conflicts of interest. Open access funding provided by Universita degli

CONFLICT OF INTERESTS
The authors declare that there are no conflict of interests.

DATA AVAILABILITY STATEMENT
Data are not available according to the statement approved by the Ethical Committee.

ETHICS STATEMENT
The study was approved by the Pediatric Ethics Committee of the